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Prevalence of behavior problems and associated factors in preschool children from the city of Salvador, state of Bahia, Brazil

Abstract

Objective:

To identify the prevalence of internalizing and externalizing behavior problems among preschoolers from the city of Salvador, state of Bahia, Brazil, and their associations with maternal mental health and family characteristics.

Methods:

This was a cross-sectional study of 349 children aged 49 to 72 months, randomly selected from 20,000 households representing the range of socioeconomic and environmental conditions in Salvador. In 1999, we assessed sociodemographic variables and family environment characteristics. In 2001, we used the Child Behavior Checklist to measure and describe the frequencies of behavior problems. We conducted bivariate and multivariate analysis to estimate associations between family and maternal factors and prevalence of behavior problems.

Results:

The overall prevalence of behavior problems was 23.5%. The prevalence of internalizing problems was 9.7%, and that of externalizing problems, 25.2%. Behavior problems were associated with several maternal mental health variables, namely: presence of at least one psychiatric diagnosis (odds radio [OR] 3.01, 95%CI 1.75-5.18), anxiety disorder (OR 2.06, 95%CI 1.20-3.46), affective disorder (OR 2.10, 95%CI 1.21-3.65), and mental health disorders due to use of psychoactive substances (OR 2.31, 95%CI 1.18-4.55).

Conclusion:

The observed prevalence of child behavior problems fell within the range reported in previous studies. Maternal mental health is an important risk factor for behavior problems in preschool-aged children.

Child psychiatry; epidemiology; families; mood disorders, unipolar; women


Introduction

Behavior problems in children are difficult to characterize, and the definitions for some of these problems, such as attention deficit hyperactivity disorder, are imprecise.11. Bauermeister JJ, So CY, Jensen PS, Krispin O, El Din AS; Integrated Services Program Task Force. Development of adaptable and flexible treatment manuals for externalizing and internalizing disorders in children and adolescents. Rev Bras Psiquiatr. 2006;28:67-71.33. Grillo E, da Silva RJ. [Early manifestations of behavioral disorders in children and adolescents]. J Pediatr (Rio J). 2004;80:S21-7. Although conceptualization is challenging, most authors agree that behavior problems include deviation from social behavior11. Bauermeister JJ, So CY, Jensen PS, Krispin O, El Din AS; Integrated Services Program Task Force. Development of adaptable and flexible treatment manuals for externalizing and internalizing disorders in children and adolescents. Rev Bras Psiquiatr. 2006;28:67-71.33. Grillo E, da Silva RJ. [Early manifestations of behavioral disorders in children and adolescents]. J Pediatr (Rio J). 2004;80:S21-7. and manifestation of signs and symptoms that do not meet criteria for mental health disorders, but suggest a future risk to the child’s development.44. Institute of Medicine, Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Washington: National Academies Press; 2009.

According to Achenbach & Edelbrock, behavior problems can be grouped into two major categories: internalizing and externalizing behaviors.55. Achenbach TM, Edelbrock CS. The child behavior profile: II. Boys aged 12-16 and girls aged 6-11 and 12-16. J Consult Clin Psychol. 1979;47:223-33. The latter are more common among boys and include negative behavior directed outward, such as frequent defiance, destruction of property, hyperactivity, anger, and impulsivity. Internalizing behavior, on the other hand, is more common among girls and includes psychosomatic disorders, social withdrawal, anxiety, extreme wariness, and sadness.

Behavior problems are diagnosed when a child exhibits persistent and repetitive patterns that break social rules and impair social interaction with others.22. Bordin IAS, Offord DR. Transtorno de conduta e comportamento anti-social. Rev Bras Psiquiatr. 2000;22:S12-S15. Academic performance, feelings of inadequacy in daily situations, a tendency to develop physical symptoms, and excessive fear in ordinary situations also require investigation.33. Grillo E, da Silva RJ. [Early manifestations of behavioral disorders in children and adolescents]. J Pediatr (Rio J). 2004;80:S21-7.

A number of studies regarding the prevalence of childhood behavior problems have been conducted in several countries.66. Matijasevich A, Murray E, Stein A, Anselmi L, Menezes AM, Santos IS, et al. Increase in child behavior problems among urban Brazilian 4-year olds: 1993 and 2004 Pelotas birth cohorts. J Child Psychol Psychiatry. 2014;55:1125-34.1313. Vitolo YL, Fleitlich-Bilyk B, Goodman R, Bordin IA. [Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren]. Rev Saude Publica. 2005;39:716-24. A review of child psychopathology studies published in 20 countries identified an estimated prevalence of behavior problems ranging from 1 to 51%.1212. Roberts RE, Attkisson CC, Rosenblatt A. Prevalence of psychopathology among children and adolescents. Am J Psychiatry. 1998;155:715-25. The overall prevalence among preschool-aged children (age 1-6 years) was 10%, while another literature review reported a prevalence range of 9.5 to 14.2% for emotional/behavior problems among children under 5.1414. Brauner CB, Stephens CB. Estimating the prevalence of early childhood serious emotional/behavioral disorders: challenges and recommendations. Public Health Rep. 2006;121:303-10. In Brazil, studies on the prevalence of these conditions within the preschool age group are insufficient.

The diagnosis of behavior problems in early childhood is imprecise and varies significantly depending on instrument cutoff points.1414. Brauner CB, Stephens CB. Estimating the prevalence of early childhood serious emotional/behavioral disorders: challenges and recommendations. Public Health Rep. 2006;121:303-10.

15. Campbell SB. Behavior problems in preschool children: a review of recent research. J Child Psychol Psychiatry. 1995;36:113-49.
-1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88. Therefore, any comparison of the prevalence of such problems is hindered by the use of varying methods and instruments.

One of the instruments most frequently utilized worldwide to diagnose behavior problems in children and youths is the Child Behavior Checklist (CBCL). An international study using the CBCL with children aged 17 to 60 months compared 19,850 children from 24 societies in developed and developing countries.1717. Rescorla LA, Achenbach TM, Ivanova MY, Harder VS, Otten L, Bilenberg N, et al. International comparisons of behavioral and emotional problems in preschool children: parents' reports from 24 societies. J Clin Child Adolesc Psychol. 2011;40:456-67. The authors reported the average prevalence of behavior problems to account for 33.3% of total problems within this age group.

Sociodemographic factors, such as low socioeconomic level, young maternal age, and low level of parental education, have been associated with a higher risk of developing internalizing, externalizing, and attention problems at age 5.1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,1818. Huaqing Qi C, Kaiser AP. Behavior problems of preschool children from low-income families: review of the literature. Topics Early Child Spec Educ. 2003;23:188-216.,1919. Slopen N, Fitzmaurice G, Williams DR, Gilman SE. Poverty, food insecurity, and the behavior for childhood internalizing and externalizing disorders. J Am Acad Child Adolesc Psychiatry. 2010;49:444-52. The proximal environment of a child – particularly the home environment, the main context of childhood development – also has a recognized influence on behavior problems. Family size and birth order, for instance, have been suggested as risk factors related to family background,1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88. although the direction of associations is not completely clear. For instance, Lawson & Mace2020. Lawson DW, Mace R. Siblings and childhood mental health: evidence for a later-born advantage. Soc Sci Med. 2010;70:2061-9. demonstrated a dual effect of family context in terms of birth order. They reported that having an older sibling may have a positive impact on a child’s mental health, while the presence of a younger sibling may have a negative impact. These findings suggest that there may be an unknown mechanism underlying the relationship between a child’s mental health and his/her birth order.

The roles of individual characteristics – particularly prematurity, gender, temperament, IQ, and race/ethnicity – on behavior problems have probably been more widely studied.1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,1818. Huaqing Qi C, Kaiser AP. Behavior problems of preschool children from low-income families: review of the literature. Topics Early Child Spec Educ. 2003;23:188-216. There is strong evidence that maternal mental disorders increase the risk of a higher levels of behavior problems and/or development of psychopathology in the child.77. Almeida-Filho N. Development and assessment of the QMPI: A Brazilian children’s behaviour questionnaire for completion by parents. Soc Psychiatry. 1981;16:205-11.,1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,2121. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369:145-57. A 2013 longitudinal Brazilian study highlighted the negative influence of maternal anxiety/depression, measured when children were 6 to 13 years old, on child/adolescent mental health problems at ages 12 to 19.2222. Fatori D, Bordin IA, Curto BM, de Paula CS. Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study. BMC Psychiatry. 2013;13:31.

Child mental health problems are fairly common and may influence development in different areas, such as cognition, socialization, and learning.2323. Zanoti-Jeronymo DV, Carvalho AM. Self-concept, academic performance and behavioral evaluation of the children of alcoholic parents. Rev Bras Psiquiatr. 2005;27:233-6.

24. Ferreira MCT, Marturano EM. Ambiente familiar e os problemas do comportamento apresentados por crianças com baixo desempenho escolar. Psicol Reflex Crit. 2002;15:35-44.

25. D'Avila-Bacarji KMG, Marturano EM, Elias LCS. Suporte parental: um estudo sobre crianças com queixas escolares. Psicol Estud. 2005;10:107-15.
-2626. Stevanato IS, Loureiro SR, Linhares MBM, Marturano EM. Autoconceito de crianças com dificuldades de aprendizagem e problemas de comportamento. Psicol Estud. 2003;8:67-76. Numerous studies emphasize the severe long-term consequences of behavior problems as predictors of inadequate adjustment throughout the life course. These predictors cross into different domains, including delinquency, abuse of psychoactive substances, major depression, long-term unemployment, and difficulties in educating one’s own children.1010. Moren-Cross JL, Wright DR, LaGory M, Lanzi RG. Perceived neighborhood characteristics and problem behavior among disadvantaged children. Child Psychiatry Hum Dev. 2005;36:273-94.,2727. Pacheco J, Alvarenga P, Reppold C, Piccinini CA, Hutz CS. Estabilidade do comportamento anti-social na transição da infância para a adolescência: uma perspectiva desenvolvimentista. Psicol Reflex Crit. 2005;18:55-61.

28. Serra-Pinheiro MA, Schmitz M, Mattos P, Souza I. [Oppositional defiant disorder: a review of neurobiological and environmental correlates, comorbidities, treatment and prognosis]. Rev Bras Psiquiatr. 2004;26:273-6.
-2929. Guttmannova K, Szanyi JM, Cali PW. Internalizing and externalizing behaviour problem scores: cross-ethnic and longitudinal measurement invariance of the behavior problem index. Educ Psychol Meas. 2008;68:676-94.

The need to obtain more precise information about child mental health has been identified in countries such as Brazil, where children do not receive adequate treatment.1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,3030. Gardner F, Shaw DS. Behavioral problems of infancy and preschool children (0-5). In: Rutter M, Bishop DVM, Pine DS, editors. Rutter's child and adolescent psychiatry. 5th ed. Malden: Blackwell Publishing; 2009. p. 882-1248. Within this context, the goal of the present study was to identify the prevalence of internalizing and externalizing behavior problems in preschool children in the city of Salvador, state of Bahia, Brazil, and the association between these problems and maternal mental health.

Methods

Study design and population

The study reported herein involved a cross-sectional design integrating a longitudinal study, started in 1997, which investigated risk factors for child diarrhea in a sample of 1,153 children living within the urban area of the city of Salvador, Brazil. The study itself was conducted in 2001, with 349 children of both genders, between 49 and 72 months of age. Detailed information on the study design and methods is available elsewhere.3131. Strina A, Cairncross S, Barreto ML, Larrea C, Prado MS. Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. Am J Epidemiol. 2003;157:1032-8.

Sampling procedure

The longitudinal study started in 1997 into which the present investigation is nested was designed to assess child development and diarrhea in a sample of 1,153 children randomly selected, by stratification proportional to the number of residents, from areas of the city of Salvador with and without basic sanitation. Detailed information on sampling and early cohort follow-up (1997-1998) is presented in Strina et al.3131. Strina A, Cairncross S, Barreto ML, Larrea C, Prado MS. Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. Am J Epidemiol. 2003;157:1032-8. To study child development within this population, we selected a subsample of 510 children who were aged < 42 months as of 1999. Of these, 365 children were located and constituted the sample for the present study.

In 2001, we located and assessed 350 children aged 4-6 years of age; complete data for all the covariates of interest were available for 349 of these subjects. This sample size was deemed adequate for estimation of the prevalence of behavior problems, assuming α = 0.05 and a statistical power of 80%.

The majority of losses (61.5%) occurred due to caregiver refusal to continue participation in the study; all remaining losses (38.5%) were due to a change of address during data collection. No statistically significant differences were found between the 349 participants of the original sample and the 190 participants lost to follow-up in relation to weight-for-height (p = 0.65), proportion of mothers with < 4 years of formal education (p = 0.72), or quality of the environment external to the household (p = 0.09).

Instruments

Child Behavior Checklist (CBCL)

This instrument was developed and standardized by Achenbach & Edelbrock at the University of Vermont in 1966 and updated in 1991 and 2001.3232. Achenbach TM, Rescorla LA. Manual for the ASEBA school-age forms & profiles. Burlington: University of Vermont, Research Center for Children, Youth, & Families; 2001. The CBCL is one of the questionnaires most frequently used to assess behavior problems in a range of cultures, and is designed to be completed by parents or those who interact with the child at home.1717. Rescorla LA, Achenbach TM, Ivanova MY, Harder VS, Otten L, Bilenberg N, et al. International comparisons of behavioral and emotional problems in preschool children: parents' reports from 24 societies. J Clin Child Adolesc Psychol. 2011;40:456-67.,3333. Njoroge WF, Bernhart KP. Assessment of behavioral disorders in preschool-aged children. Curr Psychiatry Rep. 2011;13:84-92. In Brazil, it has been used in epidemiologic studies and to measure treatment effects.1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,3434. Bordin IA, Rocha MM, Paula CS, Teixeira MC, Achenbach TM, Rescorla LA, et al. Child behavior checklist (CBCL), youth self-report (YSR) and teacher's report form (TRF): an overview of the development of the original and Brazilian versions. Cad Saude Publica. 2013;29:13-28.

We used the 1991 version of the CBCL to investigate behavior problems in our sample. This version has 118 items organized into eight independent subscales: social withdrawal, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior. Each of the 118 items is answered on the basis of the preceding 6 months, and scored on a scale ranging from 0 to 2, where 0 = not true (as far as you know), 1 = somewhat or sometimes true, and 3 = very true or often true. Total raw scores and T scores for behavior problems are calculated by adding the scores for each item. Two main categories are then created from the grouped items: internalizing and externalizing behavior problems. Gender-specific cutoffs are used to dichotomize the groups into normal and clinic.3535. Gray RF, Indurkhya A, McCormick MC. Prevalence, stability, and predictors of clinically significant behavior problems in low birth weight children at 3, 5, and 8 years of age. Pediatrics. 2004;114:736-43. Normative CBCL data suggest that scores above 67 indicate symptomatic patients with a clinical expression of behavior problems.3636. Fan RG, Portuguez MW, Nunes ML. Cognition, behavior and social competence of preterm low birth weight children at school age. Clinics (São Paulo). 2013;68:915-21.

The Home Observation for Measurement of the Environment (HOME) Inventory

This instrument is widely used within different sociocultural situations to assess the quality of the home environment during the first 3 years of life and its impact on cognitive and emotional development changes.3737. Bradley RH, Corwyn RF, McAdoo HP, Coll CG. The home environments of children in the United States part I: variations by age, ethnicity, and poverty status. Child Dev. 2001;72:1844-67.,3838. Zamberlan MAT, Biasoli-Alves ZMM. Detecção de níveis de riscos psicossociais através do inventário HOME em ambientes de populações urbanas de baixa renda. In: Zamberlan MAT, Biasoli-Alves ZMM, editors. Interações familiares: teoria, pesquisa e subsídios è intervenção. Londrina: Universidade Estadual de Londrina; 1997. p. 143-61. The full scale takes approximately 60 minutes to complete. It must be applied in the child’s home or in another environment in which the child spends most of his/her time, with the child fully awake and in the presence of his/her main caregiver. The version used in this study was developed for children ages 0 to 3 years and comprises 45 dichotomous items, with responses based on observations and answers obtained in an interview with the mother or substitute caregiver.

HOME subscales for this age group correspond to six components or factors: 1) emotional and verbal maternal responsivity; 2) absence of punishment and restriction; 3) organization and regularity of the environment; 4) provision of appropriate play and learning material; 5) extent of maternal involvement with the child; and 6) opportunities for variety in daily stimulation. The total score ranged from 0 to 45 points, and the scores obtained for each subscale enable an assessment of the child’s environment. Higher scores denote better environments, and frequencies and percentiles derived from these scores are used to calculate the environmental risk for the child’s development. We created a dichotomous variable to represent the mother-child interaction using factors 1, 2, and 5. Scores for this new indicator ranged from 6 to 25 points. The variable was dichotomized using the 25th percentile as a cutoff point.

Composite International Development Interview (CIDI)

The CIDI was developed by the World Health Organization to assess mental health disorders in line with ICD-10 and DSM-IV. It has been validated for use in Brazil and includes 17 diagnostic areas for mental health disorders.3939. Santos SA, Lovisi G, Legay L, Abelha L. [Prevalence of mental disorders associated with suicide attempts treated at an emergency hospital in Rio de Janeiro, Brazil]. Cad Saude Publica. 2009;25:2064-74. The researchers who used the instrument were trained by the CIDI Training Center at Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM). To represent maternal mental health, we used the most frequent disorders in our sample: disorders resulting from the abuse of psychoactive substances, anxiety disorders, and affective disorders. We also created a variable that represented the presence of at least one psychiatric diagnosis when the mother was diagnosed with at least one of the above-mentioned disorders.

Sociodemographic characteristics

In 2001, a pre-coded sociodemographic questionnaire was completed by the caregiver of each child as a means of assessing the family’s socioeconomic conditions. Information was collected about the child (sex, age, preschool or day care center attendance), mother (age and educational attainment), and family (family income, paternal presence, number of children under 5 in the home, and housing density expressed as number of persons per room).

Data collection and processing

The data analyzed herein were collected between August and December 2001, except the HOME Inventory, which was applied in 1999. All children were assessed in their homes by a team consisting of two psychologists and four supervised students. Following codification, the data were entered into Epi Info 6, using the double-entry method, by separate researchers. The resulting databases were cleaned, corrected, converted, and imported into SPSS version 11.0 for further analysis.

Statistical analysis

Descriptive analyses were initially conducted to characterize the sample through frequencies (for categorical variables) and means and standard deviations (for continuous variable). We determined the non-adjusted prevalence of internalizing and externalizing problems and the total prevalence of behavior problems, and obtained a discriminated profile for eight behavior problem scales: withdrawal, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior.

We then used logistic regression to calculate odds ratios (ORs) and their respective 95% confidence intervals (95%CI) to determine the association between variables related to the child (sex, age, preschool/day care center attendance), to the family (family income, paternal presence, number of children under 5 in the home, housing density), and to the mother (educational attainment, age, mental health, and psychosocial stimulation – mother-child interaction) and the prevalence of internalizing problems, externalizing problems, and total behavior problems among the preschoolers.

Finally, we included in the multivariate model only those variables that had demonstrated an association with p > 0.20 in the previous step, to assess the influence of maternal mental health on prevalence of behavior problems.

Ethical considerations

The Ethics Committee of the Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, approved this study. The parents and guardians of all participants signed an informed consent form, which explained the aims of the study and provided assurances regarding the confidentiality of the information obtained.

Results

As shown in Table 1, most of the children were male (54.7%), aged 5 to 6 years (67.6%), and attended preschool (79.9%). We found a 23.5% overall prevalence of behavior problems, and specific prevalence figures of 9.7% for internalizing and 25.2% for externalizing problems. A range of 4.3 to 26.2% was observed in the prevalence of behavior problems according to the CBCL subscales, with the greatest prevalence found for delinquent and aggressive behavior.

Table 1
Sociodemographic characteristics and prevalence of behavior problems as measured by the Child Behavior Checklist (n=349)

As also shown in Table 1, most families had an income of two or more times the minimum wage (62.7%) and were living in homes with more than one person per room (64.8%). The father was absent from 16% of families, while 35.5% had more than one child under 5 in the home and 26.1% had a low level of mother-child interaction, assessed by the HOME Inventory. Most mothers had at least primary level schooling (56.7%). Nearly half (46.4%) had at least one psychiatric diagnosis, with a 34.1% prevalence of anxiety disorders, 26.9% prevalence of affective disorders, and 13.7% prevalence of mental disorders due to use of psychoactive substances.

The bivariate analyses described in Table 2 revealed a distinct pattern of association between problem behavior and the risk factors of interest. At the individual level of child characteristics, no significant association was found between the studied variables and behavior problems, except for paternal absence, which was associated (OR 2.87, 95%CI 1.31-6.29) with internalizing problems. On the other hand, a greater likelihood of externalizing problems was found when the family earned only one minimum wage (OR 1.69, 95%CI 1.03-2.75), lived in a home with more than one person per room (OR 1.76, 95%CI 1.03-3.00), and when the mother had at least one psychiatric diagnosis (OR 2.11, 95%CI 1.29-3.46). Finally, all behavior problems were associated with paternal absence (OR 1.87, 95%CI 1.01-3.48), young maternal age (OR 3.23, 95%CI 1.32-7.91), low levels of mother-child interaction (OR 1.95, 95%CI 1.14-3.32), presence of at least one maternal psychiatric diagnosis (OR 2.84, 95%CI 1.70-4.77), and maternal anxiety disorder (OR 1.86, 95%CI 1.12-3.08), affective disorder (OR 1.83, 95%CI 1.08-3.11), or mental disorder due to use of psychoactive substances (OR 2.22, 95%CI 1.16-4.24).

Table 2
Prevalence and odds ratios of behavior problems in relation to associated risk factors

On multivariate analysis (Table 3), prevalence of any of the maternal mental health disorders assessed was associated with prevalence of behavior problems, adjusted for paternal absence, number of children under 5 in the home, maternal age, family income, number of persons per room, and level of mother-child interaction. The same multivariate model was used to test the association between maternal mental disorder and prevalence of internalizing or externalizing problems in the child, and showed that presence of at least one psychiatric diagnosis or anxiety disorder was associated with externalizing behavior (OR 2.24, 95%CI 1.35-3.74 and OR 1.70, 95%CI 1.02-2.85, respectively). However, total behavior problems were associated not only with presence of at least one maternal psychiatric diagnosis (OR 3.02, 95%CI 1.75-5.20), but also with presence of anxiety disorder (OR 2.10, 95%CI 1.20-3.58), affective disorder (OR 2.10, 95%CI 1.22-3.58), or mental disorder due to use of psychoactive substances (OR 2.40, 95%CI 1.21-4.76).

Table 3
Adjusted odds ratios for behavior problems related to maternal mental health problems

Discussion

This study shows that the presence of maternal mental disorders increases the likelihood of behavior problems among preschoolers, even after adjustment for important social and interaction factors. There is evidence that maternal mental health problems have a deleterious effect on child behavior, which may have significant repercussions on the acquisition of cognitive and social skills over both the short and long term.33. Grillo E, da Silva RJ. [Early manifestations of behavioral disorders in children and adolescents]. J Pediatr (Rio J). 2004;80:S21-7.,2323. Zanoti-Jeronymo DV, Carvalho AM. Self-concept, academic performance and behavioral evaluation of the children of alcoholic parents. Rev Bras Psiquiatr. 2005;27:233-6.

24. Ferreira MCT, Marturano EM. Ambiente familiar e os problemas do comportamento apresentados por crianças com baixo desempenho escolar. Psicol Reflex Crit. 2002;15:35-44.

25. D'Avila-Bacarji KMG, Marturano EM, Elias LCS. Suporte parental: um estudo sobre crianças com queixas escolares. Psicol Estud. 2005;10:107-15.
-2626. Stevanato IS, Loureiro SR, Linhares MBM, Marturano EM. Autoconceito de crianças com dificuldades de aprendizagem e problemas de comportamento. Psicol Estud. 2003;8:67-76.,3434. Bordin IA, Rocha MM, Paula CS, Teixeira MC, Achenbach TM, Rescorla LA, et al. Child behavior checklist (CBCL), youth self-report (YSR) and teacher's report form (TRF): an overview of the development of the original and Brazilian versions. Cad Saude Publica. 2013;29:13-28. This finding is in line with other studies, which have demonstrated that maternal mental health is an important predictor of behavior problems in children.77. Almeida-Filho N. Development and assessment of the QMPI: A Brazilian children’s behaviour questionnaire for completion by parents. Soc Psychiatry. 1981;16:205-11.,1616. Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiatry. 2004;45:779-88.,2121. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369:145-57.

The prevalence of behavior problems found in this study (23.5%) falls within the range reported in other investigations conducted in developing countries (12 to 29%).99. Giel R, de Arango MV, Climent CE, Harding TW, Ibrahim HH, Ladrido-Ignacio L, et al. Childhood mental disorders in primary health care: Results of observations in four developing countries. A report from the WHO collaborative Study on Strategies for Extending Mental Health Care. Pediatrics. 1981;68:677-83. Regarding the prevalence found in Brazilian studies, the prevalence of our sample was lower than those described by Vitolo et al.1313. Vitolo YL, Fleitlich-Bilyk B, Goodman R, Bordin IA. [Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren]. Rev Saude Publica. 2005;39:716-24. in Taubaté (35.2%) and by Feitosa et al.4040. Feitosa CA, Santos DN, Barreto do Carmo MB, Santos LM, Teles CA, Rodrigues LC, et al. Behavior problems and prevalence of asthma symptoms among Brazilian children. J Psychosom Res. 2011;71:160-5. in Salvador. However, these two studies were carried out on children at a different stage of development (age 6 to 12 years).

International studies suggest a trend toward increased prevalence of behavior problems with advancing age. For instance, prevalence ranges from 3.6 to 24% in children aged 1 to 6 years, with an average of 10.2%, and from 1.4 to 30.7% in children aged 6 to 12 years, with an average of 13.2%.1212. Roberts RE, Attkisson CC, Rosenblatt A. Prevalence of psychopathology among children and adolescents. Am J Psychiatry. 1998;155:715-25.

On bivariate analysis, low family income, absence of a father figure, young maternal age, problematic mother-child interaction, and high housing density increased the likelihood of child behavior problems in our sample.

Low socioeconomic status is one of the most frequently studied risk factors for behavior problems.4141. Bradley RH, Corwyn RF. Socioeconomic status and child development. Annu Rev Psychol. 2002;53:371-99. Such a context increases exposure to biological and psychosocial risks, which affect development through structural and functional changes to the brain and to the child’s behavior.2121. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369:145-57. In the present study, children living in families with a household income of only one minimum wage were 1.7 times more likely to exhibit externalizing problems.

According to Bradley & Corwyn, there is substantial evidence that children with low socioeconomic status manifest symptoms of psychiatric disorders and maladjusted social functioning more frequently than children who live in better circumstances.4141. Bradley RH, Corwyn RF. Socioeconomic status and child development. Annu Rev Psychol. 2002;53:371-99. However, it is likely that the relationship between socioeconomic status and behavior problems is mediated by aspects related to family dynamics and to the interactions experienced by the child; therefore, further studies are needed to examine this relationship.88. de Almeida-Filho N. Family variables and child mental disorders in a Third World urban area (Bahia, Brazil). Soc Psychiatry. 1984;19:23-30.,1111. Poeta LS, Rosa Neto F. [Epidemiological study on symptoms of attention deficit/hyperactivity disorder and behavior disorders in public schools of Florianopolis/SC using the EDAH]. Rev Bras Psiquiatr. 2004;26:150-5.,1313. Vitolo YL, Fleitlich-Bilyk B, Goodman R, Bordin IA. [Parental beliefs and child-rearing attitudes and mental health problems among schoolchildren]. Rev Saude Publica. 2005;39:716-24.

Poor environments with little psychosocial stimulation threaten the development of a child’s full potential, particularly during the first years of life.2121. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369:145-57.,4242. Shonkoff JP. From neurons to neighborhoods: old and new challenges for developmental and behavioral pediatrics. J Dev Behav Pediatr. 2003;24:70-6. We observed that children presenting problems in mother-child interaction were almost 1.9 times more likely to display behavior problems. Unlike distal risk factors, such as maternal schooling, this proximal risk factor can be modified through interventions, although few studies have been conducted in developing countries regarding the effect of psychosocial stimulation on child development.2121. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369:145-57.,3939. Santos SA, Lovisi G, Legay L, Abelha L. [Prevalence of mental disorders associated with suicide attempts treated at an emergency hospital in Rio de Janeiro, Brazil]. Cad Saude Publica. 2009;25:2064-74.

One of the limitations of this study was its sample size, which may not provide sufficient statistical power for estimation of the associations between the different risk factors and prevalence of behavior problems. Another limitation is that data collection took place in 2001, using a now-outdated version of the instrument employed to measure child behavior problems. However, given the lack of studies on this topic, we consider our findings relevant to the field of child mental health in Brazil.

In conclusion, our findings suggest that maternal mental health problems have a deleterious effect on child behavior and that these effects may be avoided through the development of programs seeking to reduce the risk of behavior disorders in preschoolers, emphasizing the need for comprehensive care of the whole family, with particular attention to maternal mental health.

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Publication Dates

  • Publication in this collection
    15 Sept 2015
  • Date of issue
    Jan-Mar 2016

History

  • Received
    23 Oct 2014
  • Accepted
    28 Feb 2015
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